What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?

Venipuncture for blood work should be performed on the affected arm.

The blood pressure (BP) cuff should not be applied to the affected arm.

The affected arm should be held down close to the woman's side.

The affected arm should be used for intravenous (IV) therapy.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect because venipuncture for blood work should be avoided on the affected arm. The mastectomy may have involved the removal of lymph nodes, which can impair the lymphatic drainage and increase the risk of lymphedema (swelling) in the arm. Venipuncture can cause further damage or infection to the arm.

Choice B reason: This is correct because the BP cuff should not be applied to the affected arm. The BP cuff can exert pressure on the arm and interfere with the blood and lymph flow. This can also increase the risk of lymphedema or pain in the arm.

Choice C reason: This is incorrect because the affected arm should not be held down close to the woman's side. The woman should be encouraged to elevate the arm above the level of the heart and perform gentle exercises to promote circulation and prevent stiffness. The arm should not be immobilized or restricted.

Choice D reason: This is incorrect because the affected arm should not be used for IV therapy. IV therapy can introduce fluids or medications into the arm that can affect the blood and lymph flow. It can also cause irritation or infection to the arm.

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Correct Answer is D

Explanation

Choice A reason: Asking the woman to reschedule the appointment for the examination is not the best response, as it may delay the detection and treatment of any potential problems. The nurse should inform the woman about the possible effect of the vaginal cream on the Pap test and offer her the option to reschedule or proceed with the examination.

Choice B reason: Asking the woman to describe the symptoms that indicate to her that she has a vaginal infection is a good way to assess the woman's condition and provide education, but it is not the initial response. The nurse should first inform the woman about the possible effect of the vaginal cream on the Pap test and then ask her about her symptoms.

Choice C reason: Reassuring the woman that using vaginal cream is not a problem for the examination is not true, as vaginal creams can alter the pH of the vaginal environment and affect the accuracy of the Pap test. The nurse should inform the woman about the possible effect of the vaginal cream on the Pap test and explain the importance of avoiding vaginal creams, douches, or intercourse for 48 hours before the test.

Choice D reason: Informing the woman that vaginal creams may interfere with the Pap test for which she is scheduled is the best response, as it educates the woman about the purpose and procedure of the Pap test and allows her to make an informed decision about whether to reschedule or proceed with the examination. The nurse should also explain the risks and benefits of both options and respect the woman's choice.

A. point out that inappropriate sexual behavior caused the infection. B. position the woman in a semi-Fowler position. C. tell her that antibiotics need to be taken until pelvic pain is relieved. D. explain to the woman that infertility is a likely outcome of this type of infection.

Correct Answer is B

Explanation

Choice A reason: Pointing out that inappropriate sexual behavior caused the infection is not helpful, as it may make the woman feel guilty, ashamed, or defensive. The nurse should avoid blaming or judging the woman and focus on providing education and support.

Choice B reason:Positioning the patient in asemi-Fowler position(head of the bed elevated 30–45 degrees) helps promote drainage of pelvic exudate and reduces the risk of abscess formation or further spread of infection. This is a key nursing intervention for patients withacute pelvic inflammatory disease (PID).

Choice C reason: Telling her that antibiotics need to be taken until pelvic pain is relieved is incorrect, as it may lead to incomplete treatment and recurrence of the infection. The nurse should instruct the woman to take the full course of antibiotics as prescribed, regardless of the symptoms.

Choice D reason:While infertility is apotential complicationof PID, it is not a guaranteed outcome. The nurse should provideaccurate informationabout risks but avoid causing unnecessary alarm. The focus should be onprompt treatment and prevention of complications.

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What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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